Chapter 5 Chapter 5 Diagnostic Coding Diagnostic Coding Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Elsevier Inc.
Chapter 5Chapter 5
Diagnostic Coding Diagnostic Coding
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
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Importance of Correct Diagnostic Importance of Correct Diagnostic CodingCoding
Diagnostic coding must be accurate because Diagnostic coding must be accurate because payment for inpatient services rendered to a payment for inpatient services rendered to a patient may be based on the diagnosis.patient may be based on the diagnosis.
In the outpatient setting, the diagnosis code In the outpatient setting, the diagnosis code must correspond to the treatment or services must correspond to the treatment or services rendered to the patient or payment may be rendered to the patient or payment may be denied.denied.
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The Diagnostic Coding SystemThe Diagnostic Coding System
Guidelines for diagnostic coding must be Guidelines for diagnostic coding must be followed when assigning codesfollowed when assigning codes
Only diagnoses that currently relate to patient Only diagnoses that currently relate to patient state should be codedstate should be coded
Payment for services may be tied into Payment for services may be tied into diagnostic coding, due to medical necessity diagnostic coding, due to medical necessity requirementsrequirements
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Sequencing of Diagnostic CodesSequencing of Diagnostic Codes
Primary diagnosis (first-listed)Primary diagnosis (first-listed) Related to the chief complaintRelated to the chief complaint Main reason for the encounterMain reason for the encounter
Secondary diagnosisSecondary diagnosis May contribute to the primary diagnosisMay contribute to the primary diagnosis Not the underlying cause (etiology)Not the underlying cause (etiology)
Principal diagnosisPrincipal diagnosis Only applicable to inpatient cases/claimsOnly applicable to inpatient cases/claims Similar to primary diagnosis for outpatientSimilar to primary diagnosis for outpatient
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Reasons for the Development Reasons for the Development and Use of Diagnostic Codesand Use of Diagnostic Codes
Tracking of disease processesTracking of disease processes Classification of causes of mortalityClassification of causes of mortality Medical researchMedical research Evaluation of hospital service utilizationEvaluation of hospital service utilization
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Use of Standard Transaction Use of Standard Transaction Code SetsCode Sets
Each transaction must include the use of Each transaction must include the use of medical and other code setsmedical and other code sets
ICD-9-CM must be used for when assigning ICD-9-CM must be used for when assigning diagnostic codesdiagnostic codes Required, per HIPAA standardsRequired, per HIPAA standards
Diagnostic codes should tie into the services Diagnostic codes should tie into the services rendered to the patientrendered to the patient Indicated by procedure codes (in Ch. 6)Indicated by procedure codes (in Ch. 6)
Physician’s fee profilePhysician’s fee profile
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History of Coding DiseasesHistory of Coding Diseases
1869: 1869: American Nomenclature of DiseasesAmerican Nomenclature of Diseases (AMA)(AMA)
1903: 1903: Bellevue Hospital Nomenclature of Bellevue Hospital Nomenclature of Diseases Diseases Standard Nomenclature of Standard Nomenclature of Diseases and OperationsDiseases and Operations
1960s-1991: 1960s-1991: Current Medical Information and Current Medical Information and Terminology (CMIT) Terminology (CMIT) (AMA)(AMA)
Current: Current: Systemized Nomenclature of Systemized Nomenclature of Medicine, Clinical Terms (SNOMED-CT)Medicine, Clinical Terms (SNOMED-CT)
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International Classification of International Classification of DiseasesDiseases
1717thth century: ICD developed in England century: ICD developed in England 1818thth century: ICD use began in U.S. century: ICD use began in U.S. 1950s: ICD used in hospitals to classify and 1950s: ICD used in hospitals to classify and
index diseaseindex disease Current: ICD-9 (9Current: ICD-9 (9thth revision) in use revision) in use
99Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Organization and FormatOrganization and Format
Three volumesThree volumes Volume 1: Tabular List of DiseasesVolume 1: Tabular List of Diseases Volume 2: Alphabetic Index of DiseasesVolume 2: Alphabetic Index of Diseases Volume 3: Tabular List and Alphabetic Index of Volume 3: Tabular List and Alphabetic Index of
ProceduresProcedures Volumes 1 and 2 are used in physician Volumes 1 and 2 are used in physician
offices and hospitals for diagnosesoffices and hospitals for diagnoses Volume 3 is used in hospitals for proceduresVolume 3 is used in hospitals for procedures
1010Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Outline of Volumes 1 and 2 Outline of Volumes 1 and 2 of ICD-9-CM of ICD-9-CM
1111Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
ICD-9-CM ConventionsICD-9-CM Conventions
1212Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
ICD-9-CM ConventionsICD-9-CM Conventions
1313Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
ICD-9-CM ConventionsICD-9-CM Conventions
1414Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
General Coding GuidelinesGeneral Coding Guidelines
Code only conditions or problems that are Code only conditions or problems that are actively managed at the visitactively managed at the visit
First, look up condition in Volume 2First, look up condition in Volume 2 Main term is the conditionMain term is the condition
Second, go to Volume 1 to assign the codeSecond, go to Volume 1 to assign the code Follow instructions from Volume 2 and Follow instructions from Volume 2 and
conventions in Volume 1conventions in Volume 1
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Illustration of Main Terms, Illustration of Main Terms, Subterms, and Nonessential Subterms, and Nonessential
ModifiersModifiers
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Code DigitsCode Digits
ICD-9-CM contains at least three digitsICD-9-CM contains at least three digits Fourth or fifth digits can also be appendedFourth or fifth digits can also be appended
Provides greater specificityProvides greater specificity Must be used if availableMust be used if available
Fifth digit codes can appear:Fifth digit codes can appear: At the beginning of the chapterAt the beginning of the chapter At the beginning of a sectionAt the beginning of a section At the beginning of a three-digit categoryAt the beginning of a three-digit category In a fourth-digit subcategoryIn a fourth-digit subcategory
1717Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
V Codes & E CodesV Codes & E Codes
V Codes are used when a person who is not V Codes are used when a person who is not currently sick encounters health services for currently sick encounters health services for some specific purpose.some specific purpose.
E Codes are used when some circumstance E Codes are used when some circumstance or problem is present that influences the or problem is present that influences the person’s health status but is not in itself a person’s health status but is not in itself a current illness or injury.current illness or injury.
1818Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
V Code UseV Code Use
V codes are used in four circumstancesV codes are used in four circumstances When a person who is not currently sick When a person who is not currently sick
encounters health services for a specific purpose encounters health services for a specific purpose (vaccination, etc.)(vaccination, etc.)
When a person with a resolving disease or injury When a person with a resolving disease or injury seeks aftercareseeks aftercare
When a circumstance influences an individual’s When a circumstance influences an individual’s health status but the illness is not currenthealth status but the illness is not current
When it is necessary to indicate the birth status of When it is necessary to indicate the birth status of a newborna newborn
1919Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
V Code ExamplesV Code Examples
2020Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
V Code Examples (cont’d.)V Code Examples (cont’d.)
2121Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
V Code Examples (cont’d.)V Code Examples (cont’d.)
2222Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
E CodesE Codes
Used to explain the mechanism for the injuryUsed to explain the mechanism for the injury Used to gather data about injury causesUsed to gather data about injury causes Should be reported in addition to the Should be reported in addition to the
appropriate procedural/diagnostic codesappropriate procedural/diagnostic codes E codes are NEVER the primary diagnosisE codes are NEVER the primary diagnosis
2323Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
E Codes (cont’d.)E Codes (cont’d.)
2424Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Table of Drugs and ChemicalsTable of Drugs and Chemicals
2525Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
E Coding ExamplesE Coding Examples
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E Coding Examples (cont’d.)E Coding Examples (cont’d.)
2727Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Signs, Symptoms, and Ill-Defined Signs, Symptoms, and Ill-Defined ConditionsConditions
Signs and symptoms codes can be used: Signs and symptoms codes can be used: No precise diagnosis can be madeNo precise diagnosis can be made Signs and symptoms are transient, and a specific Signs and symptoms are transient, and a specific
diagnosis was not madediagnosis was not made Provisional diagnosis for a patient who does not Provisional diagnosis for a patient who does not
return for further carereturn for further care A patient is referred for treatment before a definite A patient is referred for treatment before a definite
diagnosis is madediagnosis is made
2828Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
SterilizationSterilization
V25.2 should be used for sterilization for V25.2 should be used for sterilization for contraceptive purposescontraceptive purposes Elective sterilization: only V25.2Elective sterilization: only V25.2 Elective sterilization after obstetric delivery: V25.2 Elective sterilization after obstetric delivery: V25.2
as secondaryas secondary Sterilization for other reasons does not Sterilization for other reasons does not
require a V coderequire a V code
2929Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Neoplasm TerminologyNeoplasm Terminology
Benign tumor:Benign tumor: one that does not have one that does not have properties of invasion and metastasis and is properties of invasion and metastasis and is usually surrounded by a fibrous capsuleusually surrounded by a fibrous capsule
Malignant tumor:Malignant tumor: has the properties of has the properties of invasion and metastasisinvasion and metastasis
Carcinoma:Carcinoma: refers to a cancerous or refers to a cancerous or malignant tumormalignant tumor
Carcinoma in situ:Carcinoma in situ: cancer confined to the cancer confined to the site of origin without invasion of neighboring site of origin without invasion of neighboring tissuestissues
3030Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Coding for NeoplasmsCoding for Neoplasms
3131Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Neoplasm Coding ExamplesNeoplasm Coding Examples
3232Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Neoplasm Coding Examples Neoplasm Coding Examples (cont’d.)(cont’d.)
3333Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Cardiovascular System Cardiovascular System ConditionsConditions
HypertensionHypertension Malignant vs. benignMalignant vs. benign Cause should be coded when specifiedCause should be coded when specified
Myocardial infarctionsMyocardial infarctions Chronic rheumatic heart diseaseChronic rheumatic heart disease
Conditions presumed to be caused by rheumatic Conditions presumed to be caused by rheumatic feverfever
Arteriosclerotic cardiovascular/heart diseaseArteriosclerotic cardiovascular/heart disease Cardiovascular vs. heartCardiovascular vs. heart
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Classification of Diabetes MellitusClassification of Diabetes Mellitus
3535Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Pregnancy, Delivery, and Pregnancy, Delivery, and AbortionAbortion
Many codes in this category require five-digit Many codes in this category require five-digit subclassificationssubclassifications
Follow guidelines for coding deliveries and Follow guidelines for coding deliveries and complicationscomplications
3636Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Admitting DiagnosisAdmitting Diagnosis
Criteria for admitting inpatient diagnosisCriteria for admitting inpatient diagnosis One or more significant findings representing One or more significant findings representing
patient distress or abnormal findings on patient distress or abnormal findings on examinationexamination
A diagnosis established on an ambulatory care A diagnosis established on an ambulatory care basis or previous hospital admissionbasis or previous hospital admission
An injury or poisoningAn injury or poisoning A reason or condition not classifiable as an illness A reason or condition not classifiable as an illness
or injuryor injury
3737Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
BurnsBurns
Percentage of body area for code assignmentPercentage of body area for code assignment The Rule of NinesThe Rule of Nines
Severity of burnSeverity of burn First degreeFirst degree Second degreeSecond degree Third degreeThird degree
3838Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Injuries and Late EffectsInjuries and Late Effects
Multiple injuriesMultiple injuries List diagnosis in order of importanceList diagnosis in order of importance Most severe problem listed firstMost severe problem listed first
Guidelines for coding injuriesGuidelines for coding injuries Decide whether a diagnosis represents a current Decide whether a diagnosis represents a current
injury or late effectinjury or late effect Fractures are coded as closed if there is no Fractures are coded as closed if there is no
indication of “open” or “closed”indication of “open” or “closed” The word “with” indicates involvement of both The word “with” indicates involvement of both
sites, and the word “and” indicates involvement of sites, and the word “and” indicates involvement of one or two sites when multiple injury sites are one or two sites when multiple injury sites are givengiven
3939Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Common Injury Medical TermsCommon Injury Medical Terms
4040Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
ICD-10-CM and ICD-10-PCSICD-10-CM and ICD-10-PCS
ICD-10-CM will replace ICD-9-CM Volumes 1 ICD-10-CM will replace ICD-9-CM Volumes 1 and 2 (diagnosis codes)and 2 (diagnosis codes)
ICD-10-PCS will replace ICD-9-CM Volume 3 ICD-10-PCS will replace ICD-9-CM Volume 3 (procedure codes)(procedure codes)
Reasons for developmentReasons for development ICD-9-CM was not expandable, comprehensive, or ICD-9-CM was not expandable, comprehensive, or
multiaxialmultiaxial ICD-9-CM did not have standardized terminology ICD-9-CM did not have standardized terminology
and included diagnostic informationand included diagnostic information
4141Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
ICD-10-CM vs. ICD-9-CMICD-10-CM vs. ICD-9-CM Change in code book organizationChange in code book organization New categories and chaptersNew categories and chapters New six- to seven-digit alphanumeric codesNew six- to seven-digit alphanumeric codes Old injuries are to use S and T codes, by siteOld injuries are to use S and T codes, by site Expanded explanatory notes and instructionsExpanded explanatory notes and instructions Expanded dual classification systemExpanded dual classification system E and V codes are now separate chaptersE and V codes are now separate chapters New procedures get unique codesNew procedures get unique codes Combination diagnosis/symptom codes addedCombination diagnosis/symptom codes added Postoperative complication codes describe type and site or complicationPostoperative complication codes describe type and site or complication
misadventuremisadventure early complicationearly complication late complicationlate complication sequelasequela transient postoperative conditiontransient postoperative condition
New activity code categoryNew activity code category ICD-10-PCS is more specific than CPTICD-10-PCS is more specific than CPT
4242Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
ICD-10-CM Coding ConventionsICD-10-CM Coding Conventions Braces and brackets are not applicableBraces and brackets are not applicable Added conventionsAdded conventions
““and” and” Excludes 1Excludes 1 Excludes 2Excludes 2
Acute and chronic conditions can be assigned togetherAcute and chronic conditions can be assigned together Acute should be sequenced firstAcute should be sequenced first
Bilateral sitesBilateral sites Right side is character 1; Left side is character 2Right side is character 1; Left side is character 2 Bilateral is character 3Bilateral is character 3 Unidentified side requires unspecified codeUnidentified side requires unspecified code
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Transition to ICD-10-CMTransition to ICD-10-CM
Implementation could be October 2010Implementation could be October 2010 Requires higher level of clinical knowledgeRequires higher level of clinical knowledge Training is necessaryTraining is necessary Different ICD-10-CM books will be offeredDifferent ICD-10-CM books will be offered
4444Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Basic Steps in CodingBasic Steps in Coding
Locate the main term in the Alphabetic Index Locate the main term in the Alphabetic Index in Volume 2.in Volume 2. Refer to any notes under the main term.Refer to any notes under the main term. Read any terms enclosed in parentheses after the Read any terms enclosed in parentheses after the
main term.main term. Look for appropriate subterm.Look for appropriate subterm. Look for appropriate sub-subterm.Look for appropriate sub-subterm. Follow any cross-reference instructions.Follow any cross-reference instructions. Write down the code.Write down the code.
4545Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Basic Steps in Coding (cont’d.)Basic Steps in Coding (cont’d.)
Verify the code number in the Tabular List in Verify the code number in the Tabular List in Volume 1.Volume 1. Read and be guided by any instructional terms in Read and be guided by any instructional terms in
the Tabular List.the Tabular List. Read complete description and assign the code to Read complete description and assign the code to
the highest specificity.the highest specificity.
4646Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Coding Chronic Alcoholic Liver Coding Chronic Alcoholic Liver DiseaseDisease
4747Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Tabular List Coding ExamplesTabular List Coding Examples
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Tabular List Coding Examples Tabular List Coding Examples (cont’d.)(cont’d.)
4949Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Coding by EtiologyCoding by Etiology
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Four-Digit Residual Four-Digit Residual SubcategoriesSubcategories
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Combination CodingCombination Coding
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Special Points to Remember in Special Points to Remember in Volume 1Volume 1
Use two or more codes if necessary to Use two or more codes if necessary to completely describe a diagnosis.completely describe a diagnosis.
Search for one code when two diagnoses or Search for one code when two diagnoses or a diagnosis with an associated secondary a diagnosis with an associated secondary process or complication is present. See process or complication is present. See Figure 5-8.Figure 5-8.
Use category codes only if there are no Use category codes only if there are no subcategory codes.subcategory codes.
5353Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.
Special Points to Remember in Special Points to Remember in Volume 2Volume 2
Notice that appropriate sites or modifiers are Notice that appropriate sites or modifiers are listed in alphabetic order under the main listed in alphabetic order under the main terms, with further subterm listings as terms, with further subterm listings as needed.needed.
Examine all modifiers that appear in Examine all modifiers that appear in parentheses next to the main term.parentheses next to the main term.
Check for nonessential modifiers that apply to Check for nonessential modifiers that apply to any of the qualifying terms used in the any of the qualifying terms used in the statement of the diagnosis found in the statement of the diagnosis found in the patient’s medical recordpatient’s medical record
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Special Points to Remember in Special Points to Remember in Volume 2 (cont’d)Volume 2 (cont’d)
Notice that eponyms appear as both main Notice that eponyms appear as both main term entries and modifiers under main terms term entries and modifiers under main terms such as “disease” or “syndrome” and such as “disease” or “syndrome” and “operation.”“operation.”
Look for sublisted terms in parentheses that Look for sublisted terms in parentheses that are associated with the eponym.are associated with the eponym.
Locate closely related terms, code Locate closely related terms, code categories, and cross-referenced synonyms categories, and cross-referenced synonyms indicated by indicated by seesee and and see alsosee also..
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Excerpt from Alphabetic Index Excerpt from Alphabetic Index of ICD-9-CM Volume 2of ICD-9-CM Volume 2
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Excerpt from Tabular List Excerpt from Tabular List of ICD-9-CM Volume 1of ICD-9-CM Volume 1